1. A nurse must perform normal BUBBLEE assessment, along with specific health teaching on breastfeeding and transmission.
2. Role of the Nurse
2.1. Assessments
2.1.1. The nurse is to recommend HIV testing as a part of the health assessment. The center for disease control (CDC) recommend that HIV testing should be a part of screening for prenatal risk factors (CDC,2017)
2.2. Emotional counseling
2.2.1. Nurse must do a mental health assessment because an positive HIV diagnosis adds stressors on pregnant woman (Lachat et al, 2006).
2.3. Infection Control Practice
2.3.1. Routine practices are to be used (Lachat et al, 2006).
2.4. Health Teaching
2.4.1. A nurse must assess what her client knows do health teaching on breastfeeding childbirth and transmission, and the antiretrovral drug regimen of a newborn (Lachat et al, 2006).
3. Postpartum Care
3.1. Risk of postpartum bleeding is increased due to the high incidence of anemia in HIV positive women (Lachat et al, 2006).
3.2. Assessment for infection is critical to the care of mother with HIV. Assess for evidence urinary tract infections, infections related to an episiotomy. Highlight the important of changing pads (Lachat et al, 2006).
4. Conception
4.1. If both partners are HIV positive artificial or in-vitro fertilization from HIV negative sources may be required (e.i sperm donor, egg donor) (Lachat et al, 2006).
4.2. If the female test positive and the male tests negative artificial insemination is the best route to reduce the risk of transmission (Lachat et al, 2006).
4.3. If the male tests positive and the female tests negative a procedure called sperm washing should be used. This is the process by which sperm is cleansed to remove the HIV virus. Artificial insemination is also recommended with this practice (Lachat et al, 2006).
4.4. With intervention of ART and the healthcare system MTC transmission of HIV has been reduced to 1%. (AIDSinfo, 2017)
5. Childbirth
5.1. Modes of delivery (C-section or vaginal) should be based on upon mother current viral load level around week 36 of gestation (Lachat, Scott, Relf, 2006)
5.2. Cesarean sections reduce the risk of MTC transmission. It is recommended for mothers with a viral load greater than 1000 copies/ml^3. (Lachat et al, 2006)
6. Prenatal Care
6.1. As long as mother is not severely immunocompromised mother should receive regular prenatal care (Lachat et al, 2006)
6.2. Monitoring of viral load and CD4 T-cell count is required throughout pregnancy (Bennett & Gilroy, 2017)
7. Neonate Care
7.1. Upon childbirth, newborns should be limited to the exposure of maternal fluids. Bathing neonate if the temperature is stable is recommended (Lachat et al, 2006)
7.2. Neonates will carry antibodies for HIV for 1-18 months after birth (Lachat et al, 2006).
7.3. Newborn HIV testing include measuring for viral load in the bloodstream, HIV-DNA/RNA polymerase chain reaction test and a p24 core antigen level test (Lachat et al, 2006).
7.4. Newborn are to be tested within the 48 hours of birth, at 1-2 months of life and 3-6 months of life. Until HIV status is confirm, neonate is assumed to test positive (Lachat et al, 2006).
7.5. Newborn requires two positive tests to be diagnosed with MTC transmitted HIV (Lachat et al, 2006).
7.6. Antiretroviral Therapy is recommended for all neonates who are at risk for MTC transmission
7.6.1. ART prophylaxis is a one drug (zidovudine) method used to reduce the risk of HIV acquisition in neonates. This is used in newborns without confirm HIV status (example: mother adhered to ART drug regimen during gestational period) (AIDSinfo, 2017).
7.6.2. Empiric HIV Therapy is a three drug method of ART. It us used for neonates at high risk of MTC transmission (example: mother was unaware of HIV status prior to childbirth) (AIDSinfo, 2017).
7.6.3. HIV therapy is a three drug combination of antiretroviral drugs in neonates with confirm HIV (AIDSinfo, 2017).
8. Perinatal transmission rate is 41% if the viral load 100,000 copies/ ml. and the rate decreases as the viral load decreases (Bennett & Gilroy, 2017)
9. The majority (70-80%) of Mother-to-Child (MTC) transmission of HIV occurs postpartum, usually through breastfeeding (Lachat et al, 2006)
10. Human Immunodeficiency Virus is a viral infection, spread through exchange of certain bodily fluids, that attacks the human body's immune system. (CDC,2017)
10.1. Pathophysiology of HIV
10.1.1. HIV attacks the immune system, more spefically the CD4 cells also known as T-cells, T-lymphocytes, or helper cells (Bennett & Gilroy, 2017)
10.1.2. HIV Cell Cycle (AIDSinfo, 2017)
10.1.2.1. Stage 1: Binding. HIV bind to the receptors of CD4 Cells (AIDSinfo, 2017)
10.1.2.2. Stage 2: Fusion. HIV envelope and the cell membrane of the HIV join together. This permits HIV to enter the cell.(AIDSinfo, 2017)
10.1.2.3. Stage 3: Reverse transcription. The HIV virus uses the HIV enzyme reverse transcriptase to make HIV RNA to HIV DNA. This process permits the virus to enter the CD4 cell nucleus and combine with it's DNA (AIDSinfo, 2017).
10.1.2.4. Stage 4: Integration. The HIV uses the enzyme intregrase to integrate the viral DNA into the CD4 cell whilst in the nucleus (AIDSinfo, 2017).
10.1.2.5. Stage 5: Replication. The virus now uses the CD4 cell replication mechanism to make long protein chains of HIV (AIDSinfo, 2017).
10.1.2.6. Stage 6: Assembly. The newly formed HIV proteins and the HIV RNA move to the surface of the CD4 cell. They are now immature non-infectious HIV (AIDSinfo, 2017).
10.1.2.7. Stage 7: Budding. Immature cells move outside of the CD4 cell. They release the enzyme HIV protease which breaks up the long chain made during replication. The broken up pieces of immature protein now combine to make mature infectious HIV (AIDSinfo, 2017).
10.1.3. Stages of HIV
10.1.3.1. Stage 1: Acute Primary Infection
10.1.3.1.1. Occurs within 2-4 weeks post infection. People may experience flu like symptoms. Large amounts of the virus are in the bloodstream (AIDsinfo, 2017)
10.1.3.2. Stage 2: HIV Inactivity
10.1.3.2.1. HIV is active at very low levels in the bloodstream. People are usually asymptomatic. If on antiretroviral medication, this stage can last for years (AIDsinfo, 2017).
10.1.3.3. Stage 3: Acquired Immunodeficiency Syndrome (AIDS)
10.1.3.3.1. Marked by the and increase of the virus in the bloodstream and a decrease in CD4 cell count (AIDsinfo, 2017).
10.1.3.3.2. Most severe stage of HIV infection due to the fact that the immune system is severely damaged increasing the body's vulnerability to opportunistic illnesses (AIDsinfo, 2017).
10.1.3.3.3. Diagnostic requirement is a CD4 cell count below 200 cells/mm or the development of an opportunistic illness such as the flu, pneumonia, salmonella and more. These are all fatal to a person with AIDS due to the severe decrease in immune function (AIDsinfo, 2017).
10.2. Prevalence of HIV
10.2.1. According to the World Health Organization the prevalence of HIV globally is 0.8%.
10.2.2. HIV is more prevalent in Sub-Saharan Africa, 1/25 adults are living with HIV. This population accounts for 2/3 of the global population living with HIV. (CDC, 2017)
10.2.3. In Canada: The HIV incidence rate is 7.2 per 100 000 people living in Canada. (Challacombe, 2017)
10.3. Treatment Options
10.3.1. Antiretroviral treatment (ART) is the most optimal option for viral suppression. ART slows down the rate at which the virus replicates itself by inhibiting the enzymes that allow replication. (Bennett & Gilroy, 2017)
10.3.2. ARTs are often used in a three drug combination with one another. Some include: Dolutegravir, Abacavir, Lamivudine, Elvitegravir, Tenofovir and Emtricitabine. (Bennett & Gilroy, 2017)
10.3.3. Side effects of ARTs include: Loss of appetite, lipodystrophy, diarrhea, fatigue, increased triglycerides, mood changes, nausea and vomiting, rash and insomnia (AIDSinfo, 2017)
10.4. Diagnostic factors and Test
10.4.1. High sensitivity enzyme-linked immunoabsorbent assay (ELISA) test is used. This test requires blood cultures to be ran to test for viral load.
10.4.2. Viral load is used to describe the amount of HIV virus in the bloodstream. An example of a high viral load is 100,000 copies/ mL in the blood stream, low would be around 1000 copies/mL.
11. Transmission
11.1. Postpartum
11.2. Sexual Partners
11.2.1. Through exchange of Blood, semen, pre-seminal fluid, and vaginal fluid
11.3. Injectable Drug Use
11.3.1. Sharing needles with HIV positive people increases the likelihood of transmission due to exposure to bodily fluids.